DOI: http://dx.doi.org/10.12775/MBS.2014.

014

Medical and Biological Sciences, 2014, 28/2, 5-10

REVIEW / PRACA POGLĄDOWA

Weronika Jurczak, Katarzyna Porzych, Anna Polak-Szabela

NURSE’S ROLE IN TAKING CARE OF A PATIENT WITH ALZHEIMER’S DISEASE

ROLA PIELĘGNIARKI W OPIECE NAD PACJENTEM Z CHOROBĄ ALZHEIMERA

Department of Geriatrics Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz

Head: prof. dr hab. n. med. Kornelia Kędziora-Kornatowska

Summary

Along with the development of medicine, the duration of
human life lengthened. Thus, the number of people that live
to a great age has increased. One of the main health issues
concerning people in old age is dementia. The most common
cause of dementia that occurs after 65 years of age is
Alzheimer’s disease. The course of the disease is progressive
and it gradually leads to the situation when a patient is
dependent on others. In most cases, the burden of care of a
person with Alzheimer’s disease falls on the family members
and friends. It is not an easy task. Often the family is not able
to provide a proper patient care and therefore, it requires
comprehensive medical, social, educational and financial
help. The present study describes an important role of nurses,
who not only accompany patients and their caregivers, but
also educate and support them.

Streszczenie

Wraz z postępem medycyny wydłużyło się trwanie życia chorobą Alzheimera spada na osoby najbliższe. Nie jest to
ludzkiego. Zwiększa się więc liczba osób dożywających łatwe zadanie. Często rodzina nie jest w stanie zapewnić
wieku sędziwego. Jednym z największych problemów odpowiedniej opieki choremu, dlatego wymaga
zdrowotnych osób w podeszłym wieku jest otępienie. wszechstronnej pomocy medycznej, społecznej, edukacyjnej
Najczęstszą z przyczyn otępienia występującego po 65 roku i finansowej.
życia jest choroba Alzheimera. Przebieg schorzenia jest W niniejszej pracy opisano bardzo ważną rolę
postępujący i stopniowo prowadzi do uzależnienia chorego pielęgniarek, które towarzyszą chorym i ich opiekunom,
od innych. Przeważnie ciężar opieki nad człowiekiem z edukują i wspierają ich.

Key words: dementia, Alzheimer’s disease, old age

Słowa kluczowe: otępienie, choroba Alzheimera, wiek podeszły

INTRODUCTION Alzheimer, who first described the pathological

Aging is a normal physiological process. If there
are no complications in the course of the process, it can
be described as normal aging. However, in most cases
it is pathological aging, i.e. aging that has been
accelerated or complicated by chronic disease
processes [1].
Dementia is one of the most challenging health
problems in the elderly. Alzheimer's disease is the
most common cause of dementia and accounts for
approximately 50-70% of all cases of dementia. The
disease is named after the German neurologist Alois
changes characteristic of this disease [2, 3].
Number of people affected by Alzheimer's disease
is constantly growing; the incidence of the disease is
up to 8% in people over 80 years of age and concerns
almost half of this population [4]. The number of
people with Alzheimer's disease in the world is
estimated at around 15-21 million. In Poland, the
various forms of dementia concern around 500,000
people, and half of that number is dementia of the
Alzheimer type [5].
Due to an increasing incidence of this disease it is
crucial to raise awareness and spread knowledge about
the disease as well as to develop support for patients
6 Weronika Jurczak et al.
and their families. Taking care of a person with
Alzheimer’s disease is a very difficult and responsible
task that demands devotions from a caregiver. Help of
a professional therapeutic team is important. Nurse’s
tasks include not only care, performing specialist
treatments, help with everyday activities but also
accompanying, supporting and mainly educating
caregivers and patient’s family.
NATURE OF THE DISEASE
Alzheimer's is a primarily degenerative dementia
process characterised by the loss of neurons and
synaptic connections of the brain. It is a continuously
advancing process [2, 3].
In the brain of the patient two proteins with altered
conformation are deposited. β-amyloid is deposited in
the form of extracellular amyloid senile plaques. Tau
protein accumulates inside of neurons as
neurofibrillary tangles. Symptoms of the disease are
visible after many years of this pathological process in
the brain. Loss of neurons and connections cannot be
compensated by the abilities of brain plasticity. It is
macroscopically manifested by atrophy of the brain
[5].
The presence of neurofibrillary tangles and senile
plaques in brain tissue is considered to be a base of
pathological diagnosis of the disease. Disorders of
certain neurotransmitters are an important factor in the
pathophysiology of the disease. The number of
cholinergic neurons is reduced and the activity of
choline acetyltransferase is limited; however, activity
of acetylcholinesterase increases. This is connected
with a decrease in acetylcholine synthesis and an
increase in its distribution. Disorders in serotonergic,
dopaminergic and glutominergic systems are also
noted [2].
No definite cause of Alzheimer's disease has been
found. Multiply causation is indicated as there are
many factors that can be important in the etiology of
the disease. These include aforementioned pathological
changes in the brain as well as: genetic predisposition,
theories of free radicals, viral infections, inflammatory
processes in the brain and environmental factors.
Alzheimer's disease is a process that develops very
secretly and slowly. No rapid changes in clinical
condition of the patient are observed. Dementia in
Alzheimer's disease occurs in stages following one
after another. The course of the disease depends greatly
on individual characteristics of the patient and may
differ from other cases. There are several stages
depending on the clinical phase [6].
The beginning of the Alzheimer's disease is elusive
and often invisible for the patient and the family. It is
believed that mild cognitive impairment (MCI) may be
an early stage of Alzheimer's dementia. Cognitive
impairment may occur along with memory disorders,
language and visual-spatial disorders. With the
development of the disease, the patient is becoming
less independent and requires more care. In the last
stage of the disease the patient is completely dependent
on the caregiver [7, 8].
Despite the continuous development of science,
there are currently no therapeutic possibilities that
would allow a complete cure for the disease. Treatment
of Alzheimer's disease still remains symptomatic.
Applied treatments modify the clinical course and may
slow down the occurrence of symptoms but they do not
influence the regression of the disease. It is desirable to
combine pharmacological treatment with non-
pharmacological one. The effect of the use of
medications is to slow down and delay the appearance
of new symptoms, while the goal of non-
pharmacological treatment is to reduce the results of
progressive damage to the central nervous system. The
combination of these two types of therapy can improve
the quality of life of patients and their daily functioning
[3, 5].
ORGANIZATION OF CARE
Taking care of a person with Alzheimer's disease
should be comprehensive. The team holding the
therapeutic care of patients includes: a doctor, a nurse,
a caregiver, a social worker and a physiotherapist.
They must work closely together. However, it is also
required for the specialists to cooperate with the
patient’s family, mainly in the aspect of mutual
exchange of information on the biological,
psychological and social state of the patient, which
allows a better implementation of protective activities.
Proceedings in working with patients require an
adjustment of the surrounding of physical and social
environment. Interventions of the entire therapeutic
team aim to inhibit the progression of the disease and
prevention of complications. The goal is to ensure that
a patient stays self-reliant and independence as long as
possible. This allows improvement in self-esteem of
the patient and reduction of the burden on a caregiver.
 Nurse's role in taking care of a patient with Alzheimer's disease
Protective activities lead to improving the quality of
life of the patient and ensuring his safety [ 2].
Due to the large variation in the course of disease,
it is not possible to establish uniform rules of
procedure with the patient. When organizing care, it is
crucial to assess patent’s ability, capabilities, needs and
interests as well as to define the types and number of
existing deficits. Type and scope of caregiver’s tasks
change with the progression of the disease. From the
first stage the needs of the patient should be fulfilled
and his future should be planned. It is important to
create an atmosphere of safety and trust and present the
attitude of kindness, respect and acceptance of the
patient's behaviour [2, 9].
In majority of cases, these are the family members
who take care of a patient with Alzheimer’s disease;
usually a spouse or children. With the progression of
the disease, more difficult problems that unable the
family to provide the sick with proper care occur.
Patient’s family can count on emotional support and
information from the doctor, nurse and social worker
as well as Alzheimer’s organizations as it is essential to
have the knowledge of Alzheimer's disease, its stages
and symptoms to implement proper care. Along with
cooperation with the patient’s family, education of the
therapeutic team is important. A person suffering from
Alzheimer's disease should remain in their own home
for as long as possible since providing permanent
environment gives a sense of security and prevents the
appearance of additional negative behaviours of the
patient. When taking care in the home environment
becomes impossible, placing the patient in a care
institution should be considered [10].
CARE PROBLEMS
Care problems related to the Alzheimer’s disease
change during its course. Early recognition of
symptoms is very difficult; therefore, many patients
and their families do not notice or ignore them. As the
disease progresses, the scope of required assistance
increases and the type of help changes. Dementia is the
main symptom of Alzheimer's. In the patient cognitive
function disorders, problems with memory and
orientation (awareness of the place, date, season, time,
people) and other disorders of intellectual function
appear. Initially, these are sporadic but occur more
often with time. Problems in everyday functioning also
appear.
7
In the early stages of the disease the patient may
have problems remembering names and names of
objects. Often the patient does not remember the steps
he has just performed (he does not know why he has
opened the wardrobe or where he has put away a
certain item. These symptoms are very common and
may be ignored by the family and the patient. Only
when such situations are repeated and become
annoying, patient’s family start to understand that they
can be associated with the disease. In the initial period
of illness help is based primarily on supporting the
patient by reminding him names, names of objects,
dates or words. The patient may need guidance
regarding the location of various objects. Therefore,
this assistance is mostly related to patient’s memory
disorders [11].
In subsequent stages of the illness, the patient
begins to have language difficulties and a graduate loss
of communication skills occurs. There are problems
with articulation, and in an advanced stage of the
disease the ability to speak can completely disappear.
While the ability to communicate deteriorates, it is
very important for caregivers to constantly
communicate with the patient.
Along with the progress of the disease, patients
require more assistance with everyday chores such as
cleaning, preparing meals or shopping. Later, patients
also need support in the performance of personal
hygiene activities such as dressing and washing.
Changes in personality or behaviour disorders occur. In
Alzheimer's disease the patient may also suffer from
depression and hallucinations or delirium so for safety
reasons, people affected by Alzheimer's disease require
supervision most of the time. In subsequent stages of
the disease, physical impairment, problems with
walking, unnatural stiffness or tremor appear. There is
a need of assistance in performing daily activities such
as moving and satisfying physiological needs. In the
late stage of the disease, the patient becomes
completely reliant, both physically and mentally. Often
patients are not able to move around, make contact or
satisfy their physiological needs. There are also
disturbance of consciousness and a total loss of contact
with the environment
The problems that may arise during the care of a
person with Alzheimer's disease show how difficult the
role of guardian is. Only memory disorders in the early
stage of the disease when the patient is still physically
fit can constitute a huge psychological burden for a
caregiver. In subsequent stages emotional, mental and
8 Weronika Jurczak et al.
physical problems become such a large burden that a
caregiver may not be able to cope with alone. Often,
financial situation and family affairs cause additional
problems. That is why, help of the therapeutic team in
terms of knowledge, ways of coping, daily needs and
providing time off for a caregiver is crucial. In some
situations, despite help from the therapeutic team,
nursing care at home may become impossible. It may
be necessary to place the patient in a nursing home
with 24/7 supervision. Such decision is very difficult to
take and is often associated with a variety of concerns,
mostly a sense of guilt. It causes unpleasant emotions
for both caregiver and the sick. However, the carer
should be aware that if patient cannot be offered proper
care, the decision to transfer the patient to the health
care facility may be the best solution [10, 11].
Caregivers of people with Alzheimer's disease
should try to avoid situations that may exacerbate the
symptoms of the disease. One should be provident,
take care of the environment of the patient and act in
such a way as to avoid additional problems and
accidents. To ensure proper patient care and safety it is
important to take some precautions. If a patient
requires intensive supervision, the following should be
done:
- secure the apartment door to prevent escape and
disappearance of a patient;
- protect the windows so that the patient cannot
open them without help;
- remove the locks from the doors to the rooms
such as the bathroom or the patient's room;
- remove rugs, high thresholds and other obstacles
that pose a risk of falling;
- keep sharp, dangerous objects out of reach of the
patient,
- protect electrical appliances, gas stoves, sockets,
junkers and others that may pose a risk to the patient;
- make it easier to move around the apartment with
the use of facilities such as attaching strong stair
railing, brackets used to hold when going out of the
bath or when using the toilet;
- inform friends and close neighbours about the
state of the patient;
- sign the doors of rooms, objects, cabinets in order
to increase the sense of orientation in space;
- take care of the proper use of medicines by the
patient;
- protect documents and valuables because the
patient may unwittingly throw away or hide items
important to relatives;
- establish the daily routine of the patient;
- allow regular contact with a medical specialist;
- take care of caregivers’ mental and physical
health as well as relaxation;
- settle legal matters such as financial management
of the patient, will, incapacitation [12 ].
NURSE’S ROLE IN TAKING CARE OF
ALZHEIMER’S DISEASE PATIENT
Nursing is a very complex and diverse field.
Today's nurses hold many functions that result from
the mission of the profession. These include mainly
tasks related to health promotion, preventive care,
education, diagnosis, medical treatments and
rehabilitation. Nurses also perform functions for
personal development through continuous training,
obtaining qualifications and gaining broad theoretical
and practical knowledge. This profession also gives the
opportunity to teach and conduct research work in the
field of nursing. In carrying out the above tasks, the
nurse acts according to certain standards and models
respecting all the rights and obligations contained in
laws and regulations related to the profession. Before
taking actions, it is important to accurately define the
needs, conditions and nursing problems. The nurse
provides services independently and in collaboration
with the physician by executing orders [13, 14].
Caring for a person with Alzheimer's disease is a
very difficult task. Therefore, people taking care of
patients require assistance of competent persons. At
each stage of the disease support from the specialists is
needed. Although, for providing proper care it is
important to cooperate with all members of the
therapeutic team (doctors, nurses, social workers,
physiotherapists, psychologists, speech therapists), role
of a nurse is special. Her help aims at reducing the
burden on caregiver and maintaining the patient's
independence in everyday life for as long as possible.
It also includes not only caring for the patient during
the caregiver’s incapacity but also accompanying,
supporting and identifying sources of help, educating
and facilitating access to specialist care and social
assistance. The nurse strives to provide the highest
quality of life of the sick and caregiver and prevents
complications of the disease. Educational role of the
nurse is very important, especially when it concerns
care of patients with Alzheimer's disease so a caregiver
needs to be well-prepared for providing such care [15,
16].
 Nurse's role in taking care of a patient with Alzheimer's disease
Making a diagnosis for a patient who is taken care
of at home, it is necessary to collect reliable data on the
patient, his family and environment. Firstly, it is
important to establish if relatives are able and want to
take care of the sick; one should also obtain
information about biological, psychological and social
state of the patient and about functioning of his family.
When planning to leave the patient in care of his
relatives, a nurse must carefully check their resources
and verify the scope of preparations needed for
conducting proper care. These depend not only on
patient’s health but also on relatives’ knowledge, and
skills deficits, which determine the scope of nurse’s
activities. The nurse must define information that
should be passed to the family members and what
activities should be taught [17].
A nurse taking care of a person with Alzheimer's
disease and supporting a caregiver of that person has
the required knowledge and practical skills, recognizes
the patient's problems correctly, and shows support and
understanding. She can also determine the level of
functioning of the patient and adjust the appropriate
forms of therapy. The nurse, in collaboration with the
physiotherapist, selects the type and scope of the
exercise suitable to the phase of the disease. In order to
prevent muscle contractures and thrombotic disease,
passive gymnastics is used in lying patients, while a
nurse performs preventive actions against bedsore. It is
very important to educate family members and help
them to solve everyday problems. Another important
aspect of cooperation with a caregiver is offering
psychological support; a nurse must demonstrate a lot
of empathy and availability to carers and patients.
Nursing interventions improve the quality of life of
the patient and his caregiver. The main objectives to be
obtained by a nurse are:
- maintaining patient’s efficiency as long as
possible;
- delaying the occurrence of negative symptoms of
the disease;
- ensuring a sense of security to the patient and his
relatives;
- early detection and treatment of comorbid
conditions;
- suitable adaptation of living environment [15, 18].
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Received: 27.11.2013
Accepted for publication: 17.03.2014